文献摘要

鐙骨上結構完整患者之全及部份人工聽小骨置換物成效比較
Comparison of total and partial ossicular replacement prostheses in patients with an intact stapes suprastructure

Volume 4, Issue 4

關鍵字 :
鼓室成型術,聽小骨重建術,球型關節假體,部份人工聽小骨置換物, Tympanoplasty, ossiculoplasty, ball joint prosthesis, partial ossicular reconstruction prosthesis (PORP)

作者 :
Nora M. Weiss, MD ; Ha Vy DO; Wilma Großmann, MD; Tobias Oberhoffner; Sebastian P. Schraven, MD; Robert A. Mlynski, MD

譯者 :
台大醫院 耳鼻喉部 吳振吉 醫師

摘要:


Objectives: To compare the results of ossiculoplasty with two different partial ossicular replacement prostheses (PORP) to ossiculoplasty with a total ossicular replacement prosthesis (TORP) in patients with an intact stapes suprastructure.


Methods: All patients required primary or revision surgery for chronic middle ear disease and ossicular reconstruction with either a PORP or a TORP, as well as a with an intact stapes suprastructure. In total, 141 patients receiving classic tympanoplasty with PORP (N = 92), ossiculoplasty with PORP with ball joint (N = 22), or TORP (N = 27) between January 2011 and March 2017 were included in this study. The inclusion criterion was an intact stapes  suprastructure. The underlying indication for surgery was either middle ear disease, such as cholesteatoma, or revision surgery for audiological improvement. The main outcome measures were four-frequency pure tone average (0.5, 1, 2, 3 kHz) at early and late follow-up after ossiculoplasty, the effects of clinical factors including the underlying middle ear disease, and primary or revision surgery.


Results: All patients showed a significantly reduced air-bone gap (ABG 0.5, 1, 2, 3 kHz) at late follow-up (mean: 18 dB) compared to preoperative measurements (mean: 25.5 dB). A significantly better outcome in ABG closure was shown among patients with a preoperatively intact tympanic membrane, with an intact stapes suprastructure or without preexisting cholesteatoma. Outcome was not significantly influenced by the prosthesis-type, the creation of an open mastoid cavity, the status of the mucosa, or the indication for surgery.


Conclusion: TORP with an intact stapes suprastructure is a safe procedure and provides audiological outcomes similar to PORP.

專家評論:


鐙骨上結構完整患者之全及部份人工聽小骨置換物成效比較


臺大醫院 耳鼻喉部 吳振吉醫師


慢性中耳炎、膽脂瘤、或先天性聽小骨鏈異常的患者常會合併聽小骨缺損,施行鼓室成型手術 (tympanoplasty) 以重建聽小骨鏈並回復其功能,乃改善聽力之關鍵步驟。臨床上可用於重建聽小骨缺損的材料,除了患者自體的殘存聽小骨外,也常使用人工聽小骨 (ossicular replacement prosthesis)。目前市面上可取得之人工聽小骨種類繁多,其成分多為鈦金屬;而依其功能,則可大別為「全人工聽小骨置換物」 (total ossicular replacement prosthesis, TORP)、及「部份人工聽小骨置換物」 (partial ossicular replacement prosthesis, PORP) 等兩類。聽小骨重建手術 (ossiculoplasty) 對於聽力改善的成效不一,目前已知有諸多因素可能影響聽力預後,包括:潛在中耳疾病、中耳腔黏膜之通氣功能、槌骨柄 (malleus handle) 之狀態、鐙骨上結構 (stapes suprastructure) 之狀態、手術方式(如開放式乳突鑿開術 [canal wall down, CWD],或封閉式乳突鑿開術 [canal wall up, CWU])、人工聽小骨之種類或材料、以及先前手術之次數等。


本篇論文回顧性整理 2011 年至 2017 年,於德國一醫學中心的耳鼻喉科,接受聽小骨重建手術之鐙骨上結構完整之個案。共納入 141 位患者,其中 92 位使用傳統的「部份人工聽小骨置換物 (PORP)」、22 位使用可調整角度之「球形關節部份人工聽小骨置換物 (ball joint PORP)」、27 位使用「全人工聽小骨置換物 (TORP)」。作者比較三組患者手術前後之「氣骨導差 (air-bone gap, ABG)」及聽力改善情形,並分析與聽力改善成效有關之因素。


本篇論文發現,三組患者在術後短期追蹤(平均 7 週)及長期追蹤(平均 14 個月)期間,聽力皆有顯著改善。術後聽力改善情形與潛在中耳疾病、開放式或封閉式乳突鑿開手術方式、中耳腔黏膜狀態、手術前耳膜狀態、先前手術次數等因素皆無關聯。使用「全人工聽小骨置換物 (TORP)」患者之聽力,並未較諸使用「部份人工聽小骨置換物 (PORP)」患者為差。


鼓室成型術及聽小骨重建術之手術方式變異極大,患者之間的中耳狀態也大不相同,因此即使如本篇文章,已聚焦於鐙骨上結構完整之個案,且一共收集 141 名患者,可能仍因相關變數太多,從而先前文獻上所報告與術後聽力有顯著相關的因素,在本篇文章則皆未見與術後聽力相關。


值得注意者係,一般認為在鐙骨上結構完整之個案,應使用「部份人工聽小骨置換物 (PORP)」,本篇作者則在部份個案使用「全人工聽小骨置換物 (TORP)」,而術後聽力結果並未遜於使用 PORP 組。作者認為,於外耳道後壁磨開 (drilled out) 之個案,通常重建的新耳膜較大,PORP 因角度關係,其與耳膜之接觸面無法位於重建耳膜之正中央,而可能導致重建之聽小骨鏈不穩固;此種個案若使用 TORP,反而可使其與耳膜之接觸面位於重建耳膜之較中央處,且又有鐙骨上結構支撐住 TORP 以穩定之,或可獲得較佳的聽力成效。此一見解似具若干道理,值得手術醫師參考。


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